Places of Worship Registration Act 1855

To the Registrar General of Births, Deaths, and Marriages in England E+W

I, the undersigned , of , in the county of , being the person or one of the persons who certified or last certified [or being “the trustee,”or “one of the trustees,”or the “owner,”or “occupier,”or “one of the owners or occupiers” (as the case may be), of] a certain building known by the name of [or a certain dwelling house, &c. (as the case may be)], situate at , in the county of , within the superintendent registrar’s district of , [and being now resident within the same district,] do hereby declare and give you notice, in pursuance of the Places of Worship Registration Act, 1855, that the aforesaid building [or dwelling house, &c.], which was on the day of , 185 , recorded by you as a place of meeting for religious worship by a congregation or assembly of persons calling themselves [or by a congregation or assembly of Roman Catholics, or of persons belonging to the Society of Friends, or of persons professing the Jewish Religion (as the case may be)], has wholly ceased to be used as a place for public religious worship. Witness my hand, this day of , 185 .